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Friday, November 30, 2012

Aggressive efforts in the United States to grapple with the so-called “epidemic” of prescription opioid abuse is paying off, but not as officials expected. With pain pills coming under stricter controls the door is now open for a resurgence of heroin abuse with its attendant burden of morbidity and mortality, according to news reports describing the scene in states like Kentucky. The wrath of unintended consequences is set to take a terrible toll.

A recent Associated Press (AP) report appearing in the San Francisco Chronicle [November 29, 2012] describes how Kentucky officials cracked down on opioid prescribers, set up an electronic system to track pills, and plugged a pipeline of pain pills coming into the state from Florida. Those efforts worked, as opioid analgesics become more difficult to obtain, whether legally or on the street, but law enforcement then made a surprising discovery — heroin, which had long ago faded into the background, was returning with a vengeance.

According to Dan Smoot — law enforcement director of Operation UNITE, which handles drug investigations in Kentucky counties where pain pill abuse had been rampant — in the news article, “There's always some type of drug to step up when another gets taken out. We didn't know it was going to be heroin. We knew something was going to replace pills.”

Law enforcement officials in Kentucky said the heroin, which is generally snorted or injected, is imported into the United States from Mexico and Central America. Availability and cost are prime incentives: “Where a single oxycodone pill can run from $80 to $100, heroin can cost as little as $15 to $20 for a hit that will give the user the same high for 24 hours,” said Van Ingram, executive director for the Kentucky Office of Drug Control Policy.

The AP report notes that Kentucky State Police submitted 451 suspected heroin samples to its lab in 2010 and by 2011 that number increased to 749. Through September 2012, state police had submitted 1,074 cases to the lab. “I expected to see a 50 or 60 percent increase, but not double,” Ingram observed.

Furthermore, the trend in Kentucky mirrors what the U.S. Drug Enforcement Administration is seeing nationally. While seizures of marijuana, cocaine, and methamphetamine have either held steady or dropped in the past 3 years, heroin has soared 72% from 619 kilograms confiscated in 2009 to 1,067 kilograms seized in 2011.

Along with that, heroin-related deaths are on the rise. In 2011, Kentucky medical examiners reported that heroin and morphine [metabolized from heroin] were responsible for 121 of 684 overdose deaths statewide — an increase of 42% from 85 heroin/morphine deaths in 2010.

Meanwhile, seizures in Kentucky of pain pills — primarily oxycodone, hydromorphone, and methadone — peaked in 2010 and then declined 89% by 2012. Since the Kentucky All Schedule Prescription Electronic Reporting (KASPER) System, which tracks the number and types of controlled substances prescribed in the state, went into effect in 2005, the use of 4 common opioid analgesics — codeine, hydrocodone, oxycodone, and fentanyl — for nonmedical purposes has leveled off. This has been attributed to closer monitoring, which thwarts drug abusers who go from one doctor or clinic to another seeking prescriptions.

Kentucky law enforcement officials describe users as young people in their 20s who were not around during heroin's last wave of popularity. “Now, it's just the guy down the street using it. It's a whole new demographic,” said the state's chief medical examiner, Dr. Tracy Corey, in the AP news report.

The news report goes on to observe that neighboring Indiana is also seeing a rise in heroin as OxyContin gets tougher and more expensive to acquire. According to Indiana State Police Trooper Jerry Goodin, “Heroin is much deadlier due to no controls on formulation or ingredients as in prescription pills.”

COMMENTARY: We cautioned in spring 2011 [here] and again last June 2012 [here] that the crackdown on prescription opioid analgesics in the United States was fueling a resurgence of deadly heroin abuse. This new report on Kentucky is unsurprising since the state has been so focused on pain pill problems; in fact, just last summer the state legislature enacted further stringent rules governing the prescribing of controlled substances [PDF here].

Ironically, those states that have been most aggressively taking actions to control opioid analgesic prescribing are seeing the earliest and strongest comebacks of heroin, which experts claim is inexpensive, potent, and more destructive to individuals and society than prescription opioids. Besides overdoses and deaths, heroin’s return will no doubt provoke upsurges of HIV/AIDS, hepatitis, tuberculosis, and other deadly infections. Trends suggest that many victims will be young Caucasians coming from both poor urban areas and wealthy suburbs, and increasingly female.

Meanwhile, according to various reports, patients with pain are finding it increasingly more difficult to legitimately obtain much needed opioid analgesics. Many healthcare providers — burdened by onerous rules and regulations, as well as concerns about law enforcement scrutiny of their prescribing practices — are shunning opioids and turning away patients. Some pharmacies are not adequately stocking opioid medications. Left without alternatives, patients with undertreated or untreated pain may be among those joining the new generation of illicit heroin users.

Clearly, the United States has serious substance abuse problems, as do many other countries. History tells us that curbing the supply or outright prohibition have little impact on the demand for mood altering substances — whether opioid analgesics, heroin, cocaine, alcohol, or any other drugs.

This is the so-called “balloon effect” — squeeze a balloon in one place and it will expand somewhere else; stem the supply of one drug and another will take its place. According to the AP news report, they knew this was going to happen in Kentucky, as has occurred everywhere else, but they apparently developed no plans to detect and deal with the looming problems.

Certainly, giving up on the problems in frustration or abjectly liberalizing the availability of controlled substances are untenable solutions. However, it is time that decision makers at all levels — federal, state, and local — come to realize that past and current strategies have not succeeded in “popping the balloon.” Drug problems are complex and multifaceted, and simplistic solutions seeking only to restrict supply will do little to reduce demand.

Furthermore, the crux of the problem is centered less on the drugs themselves than within the people who misuse and abuse them. Individuals, families, and communities need to accept responsibility for the attitudes, beliefs, and misbehaviors that galvanize drug problems in society and find new solutions that address those at the core.

Meanwhile, as we have said before — in the case of prescription opioid restrictions, rules, and regulations — legitimate patients should not have to pay a terrible tariff in pain due to the misbehaviors of a small minority of the population and the misguided, ineffective attempts at turning the tide of drug-use problems. Perhaps, readers have solutions to propose in comments below.

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